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HomeMy WebLinkAbout010-841-25-5329-SAN-2020-233SAWYER COUNTY ZONING & CONSERVATION ADMlNf,10610 Main Street, Suite 49Hay^vard, Wisconsin 54843(715)634-8288saiiiliiriiiiifV; saw vt'rcmiiitvi'ii>.<iri'SEP 2 4 2020^ SAVWr-IR COUNTYCOUNTY SANITARY PERMIT APPLICIII accord with Chapter DSPS 383. Wis. Adm. Code andSav^ycr County Private Sewage System OrdinanceAPPLICATION INFORM A I ION - TYPE OR PRINTl'ro|)Ci1y OwMi.-r"s Naim:•&oc/~T i^v'.I'rupcfly Legal Description.GL 3 Vi Sec. .Twp, Vi N. Range Ob WIthOjPinperty Owner's Mailing Adiiress0) KJ)City, Suiteg . A/< MZip CodeLot NumberI'lionc Number( )Block NumberSubdivision Name or CSM NumberTYPE OF BUILDING: (Check one) □ State Ownedn Public 0 1 or 2 Family Dwelling - No. of bedrooms J□ city□ Village(3 Town of «•=»-*Nearest RtxidFimNum^rPUBLIC BUILDING/LAND USE: [lixplain die uso'purpose Ibr Ibispeiroil, (I.e., eanipgniund, festival, reerv.ition/enleriainmem event etc.))Parcel Tax Number: (12 digit legacy num'ber)£l X S-_S^ _LTYPE OF PERMIT:fxl POWTS Reconnection (SAN #/''?• )n POWTS Connection (SAN# - "1n POWTS Revision (SAN# - )□ POWTS Repair (SAN# • )n Other:Additional Information:•Attach a Plot Plan svith all required information per SPS 383.21•Soil Test Information (CST #^1^ - (/XI I* Gallons per davRESPONSIBILITY STATEMENT:I. the undersigned, assume responsibiiity for the installation of the POWTS activity for which this permit is issued.I'luinber's Name: (Prim)Plumber's Sign.iliirePlumber's Address (StreeL City Slate. Zip Cotlc):po PsOx 66 SjdzMPAlPRSWNo;(o7$~fS >Business Phone Number;( ?i S ) >5^ - 7OFFICE USIv ONLY:^AppflwedQ Disapprovetl□ Owner Ciivcn Keasoii forDenialileview Dale:loO-Pcniiil f'ee:ooDale Issued:COMMENTS:**Expircs 2 years from date of Issue'*'*fssuing Ageiil SignalurcExpiration date: 9-ot^~r2£>ei^Ji—CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:Rev. 04/21/15 'IseonsinDapartment of CommareeSANITARY PERMIT APPLICATIONIn accord with ILHR B3.0S, Wis. Adm. CodeAttach complete plans (to the county copy only) for tlthan 81/2x11 inches in size.CST 99-087rtnes'system, on p8aretyandBuItiilnBS201E. WashlnBton Ave.P.O. Box 70raMaiSmWI 53707-7901VO •VOI *soaper not lessSee reverse side for instructions for completing this applicationThe information you provide may be used by other government agency programsIPrivacyLaw.s. 15.04(l)(m)].I. APPUCATION INFOBMATO>l|. PRI>n;^IMFQRMATIOMty Owner Name JOSepn tteiTZlUaxlIl Ot ProoertvtProperty OwnerTCBeplProperty LoCount173 UVJMP-Ti]Hfermit NState Sanitat]Hfermit Number329793□Chech il revteion lo prevtoua appOeeilonState Plan LD. NumberGOVC Lt 3P-ST ,N,R6 fr(g)WifihOwnerit/\OuAA . Tr.cation1/4 1/4.SProperty Owner's Mailing Addreu,'5^7aa gJ.Lot Numberii3$SBEBtistea-Biock NumberXI.Zip CodePhone NumberSubdivision Name or CSM NumberITTTPEISFifillBIfrar (check one) □ State OwnednP"bllc Bk 1 or 2 Family Dwelling - No. of bedroomsa v!%geaaTown OFJWiber($rixxijrcNearest RoadLfioHIII. BUILDING USE: (ir building type is public, check an that apply)Parcel Tax Numberol1 □ Apartment/Condo2 n Assembly Hall 63 □ Campground 74 □ Church/School 85 □ Hotel/Motel 90/6 53/1□ Medical Facility/Nursing Home□ Merchandise: Sales/Repairs□ Mobile Home Park□ Office/Factory .10 □ Outdoor Recreational Facility11 □ Restaurant/Bar/Dining12 □ Service Station/Car Wash13 Q Other: spedfy.IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line 8, if applicable)A) 1. QNew 2. 3. □ Replacement of 4. n Reconnection of 5. n Repair of an§Kstern ^yi\ern JilPji'.QQly8) □ A Sanitary Permit was previously issued. Permit NumberDate IssuedV. TYPE OF SYSTEM: (Check only one)Non-Pressurized Distribution Pressurized Distribution11 ^Seepage Bed 21 □ Mound12 □ Seepage Trench 22 □ In-Ground Pressure13 □ Seepage PitI^DSystem-ln-FillExperimentalBOD Specify TypeOther41 □ Holding Tank42 □ Pit Privy43 □ Vault PrivyVI. ABSORPTION SYSTEM INFORMATION:1. Gallons Per Day^S7>2. Absorp. AreaRequired (sq. ft)3. Absorp. AreaPropose! ,ML(sq.ft.)4. Loading Rate(Gals/day/sq. ft.)>^75. Perc. Rate(MinTinch)6. System Elev.9^,3S Feet7. Final GradeElevation/^>/jOeetVII. TANKINFORMATIONCapacityin gallonsNewTanksExistincTanksTotalGallons#ofTanksManufacturer's NamePrefab.ConcreteSiteConstructedSteelFiberglassPlasticExper.App.Septic Tank orAlaldIng Tink./aoo/600-h□□□□□liftPumgTankjU^^6fOo<L6£U&.□□□□□VIII. RESPONSIBILITY STATEMENTI, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.Plumter'sName: (Print)^yysPlumber's Ac dress (Street, Citw state. ZipCodi>er'sAcdress(Street,atK,State.Zi»CodKnumber's Sigre; (No Stamps), UMP/MPRSWWo.:2.i4)f73Business Phone Number:Isswra agent SighatIX. COUNTY / DEPARTMENT USE ONLYTg Approved□ Disapproved□ Owner Given InitialAdverse DeterminationSanitary Permit Fee$170.00Date Issued5/19/29X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:iMFORXANT NOTICE: Wisconsin State Statute, Chapter 145.2A5(3), states you are required to have your septic tank pumped/inspectedat least once every 3 years.6BO«3S8(|i11/M)OtSnUBUnON: 0(to)nolloC«uMx,On«cspirToi Sofolvai<iIMIOetl»i'h'0".dwiMr,PtumbM INSTRUCTIONS1. A sanitary permit is valid for two (2) years.2. Your sanitary permit may be renewed before the expiration date, and at a time of renewal any new criteria in theWisconsin Administrative Code will be applicable.3. All revisions to this permit must be approved by the permit issuing authority.4. Changes in ownership or plumber requires a Sanitary Permit Transfer / Renewal Form (SBD-6399) to be submitted to thecounty prior to.installation5. Onsite sewage systems must be properly maintained. The septic tankfs) must be pumped by a licensed pumper wKenOve'rnecessary, usually every 2 to 3 years.6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State ofWisconsin, Safety and Buildings Division,'608<266^151.To be complete and accurate this sanitary permit application must inciude:I. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where thesystem is to be installed.It. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling.III. Building use. If building type is public, check all appropriate boxes that apply.IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair.V. Type of system. Check appropriate box depending on system type.VI. Absorption system information. Provide all information requested for numbers 1 through?.VII. Tank information. Fill in the capacity of every new/or existing tank, list the total gallons, num'ber of tanks andmanufacturer's name, indicate prefab or site constructed and tank material. Complete for atlseptic, pump/siphon andholding tanks for this system. Check experimental approval only if tanks received experimental product approval fromDILHR.VIII. Responsibility statement Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.),address and phone number. Plumber must sign application form.IX. County/Department Use Only.X. County/Department Use Only.templete plans and specifications not smaller than 81/2x11 inches must be submitted to the county. The plans mustinclude the following: A) plot plan, drawn to scale or with complete dimensions, location of hoiding tank(s), septictank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphontanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served;B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume;elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross.sectionof the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information.GRdUNDWATER SURCHARGE1983 Wisconsin Act410induded the creation of surcharges (fees) for a number of regulated practices which caneffect groundwater.The monies collected through these surcharges are used for monitoring groundwater contamination investigationsand establishment of standards. doe D'r.5*7 2.0 W. s4.Oak La.ior\, xl (^o*4s2(joff) M2.4- 5'M<=?0^ou./\dLake,y/O/>Lo+* II I'n 6r.L.**^ 35 ^5,T ^8u} •• •A.'«t/ Ot0^2*tl'A S - 53//TouiKi 0'^Co.^ mJXA 5>M - 100 * <£ TDf o4 Pflwe./" "nn!us-^<»ur(j./' Cnrouyid)Ele.ooJ-<jooS;61= fOO.SiS'B2.= fco,AS'63= lOL 35'k/c(fTbp o^" 6i. £«tO«.«r^7STg.M =■ 9^5'\\,^cale.:/"-60'3 B/ZfWwc.HhPIcviiH* 1000 / 600S.T. P'T.ftrtc f'O-ti^U'wgq'e.'? I1ANORY RASMUSSEN AND SONS^p.B0KS6CM. Wl 54821(715)798-33562.2L.0!'-?.35'-5-94 o'oe ^2'•S'4" SCH 3034 PVC MANIFOLD* V4" SCH 2729 PVC PEREORAIBD DIST.PIPE2*4" QBSERVATim WELti©"XOPnONAL TO OTHER SIDEIZ'54'-4" SCH 40 PVC FRESHAIR INCCT. Must t^m-inate Din. 12" above*Piovide Din. 7" gravel under dist. pipe 9 Danifold end.^Provide oin. 6" gravel under dist. pipe 9 vent end.^Distribution pipe to pitch 9 2" - 4" per 100' of length.^Provide oin. 2" gravel over top of distribution pipe.*Provide Synthetic cover material or 9" of unccxnpac^ marsh hayor straw.— /0L35 l4€rr^vo-«^«'^SEPTIC TANK £ PUMP CHAMBER CROSS SECTION AND SPECIFTCATTomqV' CI VENT PIPE 12" MIN. ABOVE GRADE 6>10 from door, window orFRESH AIR INTAKEFINISHED GRADEWEATHERPROOFJUNCTION BOXWITH CONDUITAPPROVEDMANHOLE COVEW/ PADLOCK f-WARNING LABERISERM" MIN.i6" MAX.?INLEIWATER TIGHT SEALSGAS-TIGHTSEALPUMP OFF ELSV. ^i.^FT.APPROVEDPIPE 3'ONTO SOLIDSOIL3" APPROVED BEDDING UNDER TANKSPECIFICATIONSINApprovedJOINTS WITHAPPROVED PIPE3' ONTOSOLID SOIL** RISER EXIPERMITTED OKIF TANKMANUFACTURERHAS APPROVALSEPTIC / DOSSTANK MANUFACTURER: JjkffSiidLTANK SIZES:SEPTIC10OOCONCRETE PAD4DOSE(aOOGAL.GAL.NUMBER DOSES PER DAY:ItZ.S-hDOSE VOLUME INCLUDINGFLOWBACK: 75^. 72 GAL.CAPACITIES: A = Zl INCHES = 313.32. GAL14.^^2 B = ^ INCHES = 24.?*) GAL^r.p.I, c = // INCHES = IQij.fZ GALD = INCHES s J/^30 GALPUMP e ALARM WIRING AS PER ILHR 16.23 WACVERTxCAL DiFfERSNCS BETWEEN PUMP OFF AND DISTR^BU^rnw tstd— » •«+ MINIMUM NETWORK SUPPLY PRSSSUR'p * N . 1.1 . . s.85 FEET¨ FELT roRcsMAiN X raiMroN mct6r'. • -rff P??TOTAL DYNA.MIC HEAD = ^alarm MANUFACTURER: 3.J". Ele.t.+raMODEL NUMBER: is PCSWITCH TYPE: goT/erPUMP MANUFACTURER: 6ou.(d5MODEL NUMBER: "EPOfiTTESWITCH TYPE: flJ,required DISCHARGE RATE HO 6PM43.5\Z.Ulo FEETINTERNAL DIMENSIONS OF PUMP TANK:length " ;LIQUID DEPTH"WIDTH DIAMETER ^oe. Herrryj.r\r\, Jr.iffiueot PumpMETERS FEETQ<S 6S 3MODEL: 3871SIZE: 3/4" SOLIDSRPM:1550HP: 0.4.EP0-5II -F )EPo4l|{CAPACrTY12 m%SJGOULDS PUMPaiNC» Mus 1COC Qua01988 Gouldi Pumpi, Inc.SPEORCiTlONS ARE SUBJECT 70 CXiNCE WTTHOUT NOTICEEllMliv* OcioMr, 1988PniNTCO IN U.SA. SEPTIC TANK MAINTENANCE AGREEMENTOWNER;//gVg/e/W/9/N/VADDRESS: S?JiO OOBST Jr/g^gT*. JIL/a/o/s ^ O^S3PHONE: (708)^2^" S*/90LEGAL DESCRIPTION OF PROPERTY: Lor ^///a/ &oi/£/ZA/A4£/^r lerr^3. f6CT/o4JTotu^S///^ /Q/iAf&£ &(m£^T. Pa/2c€L /3.//l/OL Jlo9 a/^ /ggg . A4££ 19C>PROPERTY ADDRESS: /^^^OCO l/^ZVAS OWNER(S) of the property described above, I (we) agree to submit to the County of Sawyer a certificationform (to be provided by the County), at my (our) expense, every three years and IF INSPECIED, signed by alicensed Master Plumber, Master Plumber Restricted Sewer, Journeyman Plumber, or WI POWTS InspectorOR IF PUMPED, a licensed septage hauler. The form shall state and certify the following:1) The current operaUng condition of the private sewage system, and2) That the septic tank was recently pumped by a licensed septage luiuler OR it was inspected and is less thanone-third full of sludge and scum.I (we), the undersigned, have read the above requirements and agree to maintain the private sewage system inaccordance with applicable State standards and the Sawyer County Private Sewage System Ordinance.OWNER(S)Date: /^99^ Date:STATE OF. Xl/iiioi ^Personally came before me thijnamed person($) who executed the foregoing instrument a^d knowledge die same.Personally came before me this ///^ day of ''yXJaA^ 19 v ying instrument a6d ^ncthe aboveNotary Public, State of -X"/SMy commission expires lflo(>fzoo^ Wisconsin Oopartment of CommerceSafety and Bulldlnos DIvlalonGENERAL INFORMATIONPRIVATE SEWAGE SYSTEMINSPECTION REPORT(ATTACH TO PERMIT)Permit Holder's rtame:"■■ertnaWA□ City □ Village Q^ownoi:CSTBMEIev.rInsp. BM Elev.:lOOBM Description:Tc^ csT'C-wt Tb«4VScounty:1<V-sanitaryPermit'No.:32-*^-7*13 / qq-lO'T^state Plan ID No.:Parcel Taa No.;OIQ 2.5-- S-SIITANK INFORMATIONTYPEMANUFAaURERCAPACITYSepticHu (Tcotj- CLowvlooI.OoODosingIt VbOOAerationHoldingELEVATION DATATANK SETBACK INFORMATIONTANKTOP/LWELLBLDG.Vent toAir IntakeROADSeptic+X0-moWO+V0NADosingt|e+ IItlNAAerationNAHoldingPUMP / SIPHON INFORMATIONManufacturerDemandt-((^GPMModel Numbersu P-TDHs.6r f!i«""4.6iTDHii.t,t,FtForcemainLengthDia. t"Oist.ToWellSTATIONBSHIFSELEV.Benchmarkw.sfe1 OOBIdg. SewerSt/Ht Inlet-IllSTiVftSt/Ht OutletDt InletDt Bottom10.^^AM.iHeader/Man.ioD*iDist. PipeBot. SystemFinal GradeOp .AH.S€rSOILABSORPTION SYSTEM ST S nf.tBED/TRENCHDIMENSIONSWidth 2Length ,S6.irNo. Of Trenches•2_PITDIMENSIONSNo. Of PitsInside Dia.Liquid DepthSETBACKINFORMATIONSYSTEM TOP/LBLDGWELLLAKE/STREAMLEACHINGCHAMBEROR UNITManufacturer:TypeCISystem; T"*~4S0•L"aoo±. 2.TS"Model Number:DISTRIBUTION SYSTEMHeader/ManifoldLength DiaDistribution Pipeft)Length Dia.SpacingX Hole SizeX Hole SpacingVent To Air IntakeSOIL COVERX Pressure Systems OnlyXX Mound Or At-Grade Systems OnlyDepth OverDepth OverXX Depth OfXX Seeded/SoddedXX MulchedBed/Trench CenterBed/Trench EdgesToptoil□ Yes □ No□ Yes □ NoCOMMENTS: (include code discrepancies, persons present, etc.)BH ®f*t-OiACvlflf 4o UV«. AST- -ft*- «^|l disi^T ,ifr-e<t«fc_.Plan revision required? □ Yes (YnoUse other side for additional information.SBD-6710(R.a/97)c23DateImpector's SignatureCert No ADDITIONAL COMMENTS AND SKETCHSANITARYPE.«WIITNUMBER: 99 - tO'?( i- Wisconsin Oepartmeni of CommerceDivision of Snlely ano BuildingsDuroau of Iniegraled ServicesSOIL AND SITE EVALUATIONin accordance witti s. ILHR 03.09, Wis. Adm. CodePage/ of yAttach complete sue plan on paper not less than 8 1/2 x it inches m size. Plan mustinclude, but not limited to: vertical and horizontal rolorenco pomt IBM), direclion andpofconi slope, scale or dimensions, north arrow, and location and distance to nearest roadAPPLICANT INFORMATION - Please print all Information.Pcrsoniil inlotinalion you provide may l>u iiwil Itii WMaiiulmy imrfKisus (Privacy l..ivy. •, IS 01 (1) (mj)Property Owner ^.......Property Owner's Mailing Address'2 I.'- /.v<(.' Ur..-I n yCity State Zip Code Phone NumberC'U ^\XL I c-cY^: \ (7oi )'/;'/•Countyi'wyf.\ M /Parcoj I 0 0r'/v - yn S"il|Property LocationGovl, Lot 1/4Reviewed byh\UJ M oi-^Date1/4.S T Vf .N.fl S* €^)WLoltr■+PQiockeSubd. Nnino or CSMH□ City □ Village 0 Town Nearest RoadQ Now Construction Use: [3 Residonlial / Number ol bediooina _ Addition to oxislmy building0 Roplacomont Q Public or coinmorcinl - Dosciilio:Code detived daily Itow O god Recommended design loading rate .'Y bod, gpd/lf ^ trench, gpd/ft^Absorption area required _6Vj_bed, fl^ . trench, ft 2 Maximum design loading rate . bed, gnd/ftg > £ trench, gpd/ft2Recommended Inliltration surface e!ovation(s) 9$-^^ It (as rolorred to site plan benchrnarft)Additional dosign/sito considerations tT-r-i y.c-/i-m ■ i'. pfii ^v.-c... j,\'t rri-^a, ri(_ ,, Flood plain olovniion. If applicable _ZZm', 'IParent materialf "0. 1S = Suttiible lor systemU = Unsuitable for systemConvontianalHs □ UMoundys GuItnGruunrl Prussutolil S □ UAT GradeGs GuSystem In FillS S □ UHolding Tank□ S S USOIL DESCRIPTION REPORTHorizonDoptMIn.Dorniii.iiit Cnliirf.ljilSCllMottlesOu. Sz. Cent. Coloiti.'xluniStructureGf Sz, StiCoiisisionciiDoundatyRootsGPD/lt2Bed TrencliI<: vr•7^: '!>< Ti/y//#"C9vr-(-=7-?va' y/y/'r-'L.a(:Cyry/v i/i3/XBoring IIIGroundelov.Depth tolimitingfactort-i- m.Remar<s-■)» "j—,'{<Boring ffjL- :jQ/a's h/ 'v'lCsC(t:5y/0.JC-'>—-7 GS"'fs d-Cy/yrtO'ti-Cc-stl, x.J_—Groundelov,/rc JiJDepth tolimitingfactorIn,Remarks:-.<i ( 0(rGST Name (Please Prir^^g ZIRjVRR #1 Pn-' 1 T'l 'Signature' V L..UTelephone No,y/r- 767-Address .. ' KlJ/-Mason. Wl 54856() ^ ()Oaiu y . -/'/ CSTNumbor 0.) '*"75)'^' PROPERTY OWNER.PARCEL I.O.# do •• W/ • 0^ *53llSOIL DESCRIPTION REPORTPageHorizonDepthIn.Dominant ColorMunsellMottlesOu. Sz. Cont. ColorTextureStructureOr. Sz. Sli.ConsistenceBoundaryRootsGpnm^Trench/oV755"//? y/GIS0S6>Mf^5-70y-/(,/fs'y/? ?■///70ylC_Osiaif'CO,73T'.s'y/P syjCos—■,r.9Boring #P-GroundeJav. ^1$LMOepSr toHmltlngfactor>7$jn.Boring #Remarks;Qreundelev.OapOitolimitingfactorBoring #Grounddev.H.D^tOlindtingfactor^br.Boring #Remarks:HorizonDepthfat.Dominant ColorMunsdlMottlesQu.Sz. Cont ColorTextureSInictureGr.Sz.Sh.ConsistenceBoundaryRootsGPOfft®Bed .Trench.Remarks:Groundelev.^ft.DepUi tolimitingfactor^In.Remarks:SBD4330(a07»8) 0 ■(- I"!U-t ^// Qj4 Ui - pr- rv/v-/?9vJI«-VS?S. ?5 '" "3 f^L^?liict rtu^i' =-r.k - .r ^il/syAiO \ ' 6eAZai\<jt.A ^aiA</"i.../.<l oOle^ ^t'4l4 - / - OoA ■ "l^p a"^- /at)//tftf )(Z'l(\J0i'fl9-\ SBl ' /caPr'fiQ ^ ho. pr'-' /o/.^r'9;rp'5'r'Viil__E-1-Zx^r. XD«gp'??f9 K-S-S'lCp"^vu,^ Y- % • f *7